pediatric order set 2 - jersey shore hospital order set _2_.pdfpediatric order set 0 through 16 yrs...
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Pediatric Order Set 0 through 16 yrs age
Addressograph Stamp
1. [ ] Place in Observation: [ ] Monitored Telemetry Bed [ ] Unmonitored Bed OR
[ ] Admit to Inpatient: [ ] Med-Surg Telemetry Monitor [ ] Med-Surg
2. Diagnosis: _______________________________ Admit to: Dr ______________________________________
3. Code Status: [ ] See Completed Code Sheet * Note: No Code verbal order may only be taken in emergency situations
4. Labs: [ ] CBC, U/A, Chem 7, PT, PTT [ ] Amylase and lipase [ ] Blood Cultures times ________ site(s)
[ ] CMP [ ] BNP [ ] Fasting Lipid Profile (if not done as outpatient- within last 3 months)
[ ] Throat Culture [ ] Other _______________________________
[ ] MRSA screens for all patients readmitted within 7 days, nursing home patients, personal care home residents and group home residents. (Maintain contact precautions until negative result obtained.)
5. Studies: [ ] Portable Chest X-Ray on arrival if not done in ER
6. O2 via ____________________ ; ______ L/min.; [ ] Continuous [ ] prn [ ] Maintain SaO2 __________ %
7. SVNs: [ ] Duoneb Q _______ hr [ ] W/A [ ] prn
[ ] Other ________________________________________________Q ______hr [ ] W/A [ ] prn
8. Vital Signs [ ] Med-Surg (4hr) [ ] Observation (q 2hr) [ ] Neuro Signs q _______ hr
9. Activity: [ ] Absolute bed rest [ ] B.S. Commode [ ] BRP [ ] Elevate HOB 45-90 ˚ [ ] Ad lib
10. Diet: [ ] NPO [ ] Clear Liquids [ ] Age Appropriate Regular Diet [ ] ADA Diet ___________ Calories
11. Chart I & O [ ]
12. Weigh Daily [ ]
13. IV solution: _____________________________Rate ____________ [ ] Saline Lock with routine flush
14. Consults: [ ] Dr_________________________________ [ ] Dietary [ ] SS [ ] PT [ ] OT
_________________________________________ Physician Signature
Date Time
Pediatric Admission Order Set Addressograph Stamp
Patient Height __________ Patient Weight ________ lbs = KG _________
Pre-existing [ ] Renal Impairment [ ] Hypertension [ ] Diabetes Mellitus Conditions: [ ] Liver Impairment [ ] Pregnant [ ] Breast Feeding
Date/Time
Pre-admission Medications: Include all over-the-counter and herbal medications.
All Medications must be reviewed prior to discharge and circled Yes or No
C O D E
Continue while Inpatient
Continue on
Discharge
Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N
Date/Time Medications (All medication calculations to be checked by two RNs and calculated on Kg weight)
[ ] Tylenol Tablets / Elixir / Suppository ____________mg po/rectal q 4 hours prn
Alternate with
[ ] Ibuprofen Tablets or Elixir ____________mg po q 6 hours prn
For pain or temperature greater than _________________
Y N Y N
Date & Time GENERAL ORDERS Date & Time MEDICATION ORDERS Continue on
Discharge
Y N Y N Y N Y N
Y N Y N Y N
Code Key Rx Prescription Bottle ? Unsure or Questionable Ph Pharmacist Called ER ER Documentation L Written or Printed List V Verbalized List
Allergies
Addressograph Stamp
Date & Time GENERAL ORDERS Date & Time MEDICATION ORDERS Continue on Discharge
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Allergies
Pediatric Vital Signs Addressograph Stamp (Please place this page in Bedside Chart for vital sign reference) Vital signs remain relatively constant throughout adult life. However, as infants and children grow and age, the normal range changes. Refer to the two following tables for normal vital signs for this pediatric admission.
Age (years)
Respiratory Rate (breaths/min)
Heart Rate (beats/min)
<1 30-60 100-160 1-2 24-40 90-150 2-5 22-34 80-140 6-12 18-30 70-120 >12 12-16 60-100
Lower Limits of Systolic Pressure 0-28 Days: 60mmHg
1-12 Months: 70mmHg
1-10 Years: 70mmHg + (2 times age in years)
Age
Heart Rate
Blood Pressure (mmHg)
Respiratory Rate(breaths/min)
Premature 120-170 55-75 / 35-45 40-70 0-3 mo 100-150 65-85 / 45-55 35-55 3-6 mo 90-120 70-90 / 50-65 30-45 6-12 mo 80-120 80-100 / 55-65 25-40 1-3 yr 70-110 90-105 / 55-70 20-30 3-6 yr 65-110 95-110 / 60-75 20-25 6-12 yr 60-95 100-120 / 60-75 14-22 >12 yr 55-85 110-135 / 65-85 12-18 Source: http://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm 03/18/11
Pediatric Discharge Orders Addressograph Stamp
1. Discharge patient on all medications circled Yes and enter on Medication Card
2. Discharge patient to: [ ] Home [ ] Home Health ___________________________________________________________ [ ] Hospice [ ] Other: _______________________________________________________________
4. Discharge Diet Instructions:
[ ] As tolerated [ ] Low sodium diet [ ] If diabetic, ______________ Calorie ADA Diet [ ] Other: _______________________________________________
5. Discharge Instructions: [ ] Return to School on _____/______/_____ [ ] Note Provided
[ ] Homebound Schooling
6. Treatments / Other
7. Outpatient Lab: [ ] Yes [ ] No If yes Specify Type______________________________
Date / Time ________________________________________________________________________
8. Home Oxygen [ ] ___________________________________________
Oxygen Liter Flow ________ /min
9. Appointment with Dr. ______________________ Location _____________________________________
Please call office immediately to schedule a return visit in _____________ Phone Number _______________
10. Report to Physician: [ ] Short of Breath [ ] Fever [ ]Swelling [ ]Nausea [ ]Vomiting [ ]Pain
[ ] Excessive Diarrhea
11. [ ] Fax Discharge Orders and Patient Medication List to Office.
12. [ ] Patient and family discharge education
13. Vaccine Status: [ ] Follow-up in office for a vaccination if patient is a candidate and did not receive while in the hospital
Revised 2/12
Physician Signature
Date Time